Ivy Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last inspection in March 2023, we found the provider’s quality assurance arrangements to be ineffective. This was a breach of Regulation 17 [Good governance] of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. Although there were still some improvements to be made, enough progress had been made at this assessment and the provider no longer remained in breach of Regulation 17. Whilst there were still some improvements to be made relating to staff being responsive to people’s requests for assistance, people being treated with dignity, variable feedback about staffing levels and not all risks to people being safely monitored; significant improvements had been made to develop a positive culture at the service. People indicated the service was well managed and led. Staff were supported and valued. The provider’s governance arrangements were much improved to monitor people’s experience and to drive improvement.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us they believed the registered manager to have the skills, knowledge and experience to support them to deliver a good level of care to people using the service. All staff spoken with confirmed the registered manager was accessible, visible and approachable.

There was a clear management structure in place at Ivy Court with easily identifiable lead roles. The registered manager was visible and had an ‘open door’ policy whereby they encouraged people using the service, relatives and staff to speak with them about any issues, concerns or work-related issues. Comments from relatives included, “I know the manager. There is an ‘open door’ policy, and I can speak to them when I visit” and “I do know the manager and we have a chat and talk about stuff all of the time. They are very visible, and we can just have a word whenever.”

Staff told us they felt able and confident to raise issues or concerns with the registered manager and management team. Staff told us they had a ‘voice’ and felt empowered and able to discuss topics and raise issues of concern. A staff member told us, “We can speak our minds and can make suggestions.” Staff told us the registered manager was approachable and effective in their role. A member of staff stated, “X [registered manager] is good. They want everything to be right” implying the registered manager had high standards.

Effective arrangements were in place for gathering people’s, relative’s and staff’s views relating to the quality of the service provided and those relating to their employment and what it was like to work at Ivy Court were conducted in March 2024. The majority of comments made by people using the service and relatives were positive. Where areas for improvement were cited, these referred to staff response times to answering call alarms. We found in reaction to these comments that staff response times were being monitored. Staff meetings were held to give the management team and staff the opportunity to express their views and opinions on the day-to-day running of the service. Staff told us they had a ‘voice’ and felt enabled and able to discuss topics and raise issues of concern.

As previously stated, the provider and management team recognised staffs’ diversity, doing what they could to protect their equality characteristics. Staff told us they felt supported by the registered manager and organisation. A member of staff told us, “You can call on X [registered manager] at any time.”

The registered manager had effective arrangements in place to engage with and involve staff. This referred to seeking staff’s views relating to their employment and staff attending regular meetings on the day-to-day running of the service. As stated previously the ‘Heart of Gold’ initiative was in place to recognise and reward employees for their achievements and contributions to the organisation.

The registered manager demonstrated a good understanding of regulatory requirements, and the improvements made since our last inspection to the service in March 2023. Staff were very complimentary regarding the registered manager and senior management team.

Relatives were complimentary regarding the management of the service, indicating the service was well managed and led. People and relatives drew a distinction between the current and previous managers, noting there had been an overall improvement since our last inspection to the service. Comments included, “From my experience it [Ivy Court] is well managed. When we were looking for a place, this had a more confident feel and heads above what we saw and was the right one for us” and “I have confidence in them.” Five out of six relatives stated they would recommend the service to others. A relative told us, “I would have no hesitation in recommending Ivy Court.” The provider’s quality assurance arrangements monitored people’s experience through its internal auditing processes. This information was used to help the provider, registered manager and management team, drive improvement, including the monitoring of trends and lessons learned. However, improvements were required to ensure risks to people were monitored and mitigated. Staff response times and responding to people’s immediate needed to improve. Improvements were also needed to ensure staff received specialist training relating to the needs of people being supported. The registered manager understood their role and responsibilities and were able to demonstrate effective oversight of the service. In addition to regular audits and trackers, daily meetings, clinical risk meetings and a daily ‘huddle’ were conducted. The registered manager ensured they kept themselves and staff up to date with current guidance and learning by accessing the Care Quality Commissions website and reviewing other guidance. Memos were displayed in the staff room and messages were emailed to staff to ensure they received key information in a timely way. Statutory notifications were sent to the Care Quality Commission following a serious injury or where a safeguarding concern had been raised with the Local Authority.

People and relatives were aware that Ivy Court worked in partnerships with other agencies.

The registered manager and staff told us how they worked with other professionals and received support and guidance when needed. They spoke positively about working in partnership with others and how this had led to better outcomes for people.

Documentary evidence indicated the management team and staff worked in partnership with key organisations to support care provision, service development and joined-up care. The registered manager confirmed the service had a good working relationship with a range of professionals and services, for example, Local Authority, Integrated Care Board [ICB], Speech and Language Team [SALT], local GP surgery, dietician and dementia team.

The registered manager spoke about encouraging staff to speak up with ideas for improvement and actively invested time to listen and engage with staff. There was a robust sense of understanding and trust between the registered manager, senior management team and staff.

There were processes in place to ensure that learning happened when things go wrong. The registered manager spoke about the service’s achievements, particularly about making improvements since their last inspection in March 2023. The Local Authority noted improvements with the service during their visits and a restriction on placements at Ivy Court was partially lifted in April/May 2024 in recognition of this.